What Burning Man Can Teach Healthcare

Oh, good: it's Burning Man week.  For some people, it's the highlight of the year, an expression of creativity, community, and freedom unlike any other.  It's Woodstock, Fashion Week, and the Fringe Festival all rolled together, only set in the Nevada desert.

For others, it is 70,000 wannabe hippies/hipsters gathering together for a week of hard partying: public nudity, drugs, and sex, plus burning some "art." 

Either way, it couldn't possibly have anything to teach healthcare, right? 

Credit: Mixmag

Maybe.  But what many do not realize is that Burning Man espouses ten guiding principles, and it is worth taking a look at those and how they could or should be applied to healthcare. 

Radical Inclusion
Anyone may be a part of Burning Man. We welcome and respect the stranger. No prerequisites exist for participation in our community.

Healthcare translation: Healthcare is fully of hierarchies.  Doctors know more than nurses, clinicians know more than administrators, and everyone knows more than patients.  Just stop it: we each know something of value, and no one knows more about a patient's health than the patient.  We have to learn how to share and use all that knowledge.

Gifting
Burning Man is devoted to acts of gift giving. The value of a gift is unconditional. Gifting does not contemplate a return or an exchange for something of equal value.

Healthcare translation: Whether we planned it or not, healthcare has gone from acts of compassion to a business.  There is still plenty of compassion, thankfully, but each has to be weighed against its effect on the bottom line.  Let's get back to the focus on doing the right thing, unconditionally, not on the profitable thing.

Decommodification
In order to preserve the spirit of gifting, our community seeks to create social environments that are unmediated by commercial sponsorships, transactions, or advertising. We stand ready to protect our culture from such exploitation. We resist the substitution of consumption for participatory experience.

Healthcare translation: Tired of seeing healthcare ads?  Tired about reading about healthcare CEO salaries?  Tired of "non-profit" healthcare organizations making lots of money?  It's time to care less about the commercial aspects and more on the participatory experience of helping people be healthy. 

Radical Self-reliance
Burning Man encourages the individual to discover, exercise and rely on his or her inner resources.

Healthcare translation: Doctors don't make us healthy.  Hospitals don't make us healthy.  Drugs don't make us healthy. They each play important roles, but it is up to each of us to figure out our path towards our best health.  How do we help people do that?  

Source: Burning Man Journal

Radical Self-expression
Radical self-expression arises from the unique gifts of the individual. No one other than the individual or a collaborating group can determine its content. It is offered as a gift to others. In this spirit, the giver should respect the rights and liberties of the recipient.

Healthcare translation: Movements like DYI health or bio-hacking are often seen by mainstream medicine as misguided at best and dangerous at worse.  There certainly are risks that need to be recognized, but also benefits.  Health care treatments are not going to remain exclusively in the control of health care professionals; that is scary to some, but should be seen as opportunities for everyone.  

Communal Effort
Our community values creative cooperation and collaboration. We strive to produce, promote and protect social networks, public spaces, works of art, and methods of communication that support such interaction.

Healthcare translation: Healthcare should be all about cooperation and collaboration.  Unfortunately, it isn't.  It is too often about silos and competition, turf and control.  That has to stop.  Our health is better with cooperation and collaboration with others. 

Civic Responsibility
We value civil society. Community members who organize events should assume responsibility for public welfare and endeavor to communicate civic responsibilities to participants. They must also assume responsibility for conducting events in accordance with local, state and federal laws.

Healthcare translation: It is easy to only care about our own health.  It is easy for healthcare professionals to focus only on the health of the people they treat.  But we all must recognize that most of what drives our health comes from outside the healthcare system.  Taking responsibility for social determinants of health and other matters of public welfare is essential.

Leaving No Trace
Our community respects the environment. We are committed to leaving no physical trace of our activities wherever we gather. We clean up after ourselves and endeavor, whenever possible, to leave such places in a better state than when we found them.

Healthcare translation: What is the environmental footprint of our healthcare system?  Think of all those buildings, all those parking lots, all those devices, all the byproducts (e.g., medical waste).  What are we doing to the community, the environment, and the future? 

Participation
Our community is committed to a radically participatory ethic. We believe that transformative change, whether in the individual or in society, can occur only through the medium of deeply personal participation. We achieve being through doing. Everyone is invited to work. Everyone is invited to play. We make the world real through actions that open the heart.


Healthcare translation: Healthcare is still struggling to be "patient-centered."  The fact that it might be thought of as anything else shows how far off it is in terms of participation.  Healthcare is also still too much of a "white man's" world.  The voices of patients, the voices of women and minorities, the voices of those not actively seeking (or not able to obtain) care -- all must be heard.  

Source: Time

Immediacy
Immediate experience is, in many ways, the most important touchstone of value in our culture. We seek to overcome barriers that stand between us and a recognition of our inner selves, the reality of those around us, participation in society, and contact with a natural world exceeding human powers. No idea can substitute for this experience.

Healthcare translation: Too much of our health is in the future.  "I'll start my diet tomorrow."  "I'll think about a living will when I'm old."  "My doctor can just give me a pill."  Our health starts today.  Our sense of it now drives what it can be tomorrow.  The more we are aware of it in the immediate, the more reminded we are of how connected it is to the people and things around us.  Experience health now. 

Burning Man is not an just event that happens in a given place for a given time.  It is a "culture of possibility."  And, yes, those possibilities are things healthcare can learn from. 

First, We Blow Up All the Hospitals

A few recent stories are, I believe, reaffirming one of the big problems about healthcare: hospitals are 19th century institutions operating under 20th century business models in the 21st century.  It's time to rethink what we want a "hospital" to be. 

Atrium of Lucile Packard Children's Stanford  Credit: Steve Babuljak, Architect Magazine

The Boston Globe reported on Stanford's new Lucile Packard Children's Hospital, which cost a cool $1.3 billion and is touted as, of course, the "hospital of the future."  As they describe it, it doesn't look like a hospital at all, but rather: "It is some hybrid of hotel, museum, and high-tech laboratory."

The Globe notes a similarly ambitious, $1.2 billion renovation at Boston Children's, along with big hospital projects in numerous other cities.  "These hospitals are kind of high-tech hotels,” Mark Wietecha, president of the national Children’s Hospital Association told the Globe. “Everybody’s competing by building cooler hotels. They can do more, save more lives, all good stuff — but not cheap."

Then there was the NBC News story on the debacle with the new VA hospital in Denver.  Again, it's big and beautiful, another "cool hotel."  However, it took 14 years to plan and build -- 5 years late -- and its costs ballooned from $328 million to, umm, $1.73 billion (and counting...), despite somehow neglecting to include a place to treat PTSD, which will require further investments.  

Inside the Ricky Mountain Regional VA Medical Center Credit: Dan Elliott/AP

Meanwhile, the VA continues to struggle with how to improve access to services for veterans generally.   

The problem is that hospitals are big and getting bigger, going from building to buildings to campuses.  They are expensive and getting more expensive.  At some point, we have to ask: is this really how we want to spend our healthcare dollar?

Some hospitals are figuring other ways to spend their -- I mean, "our" -- money on our health.  Take Nationwide Children's Hospital.  Located in a somewhat blighted neighborhood of Columbus (OH), its Healthy Neighborhoods Healthy Families (HNHF) program "treats the neighborhood as the patient," as their summary in Pediatrics put it.   

Source: Nationwide Children's

The hospital is leading a partnership that has built 58 affordable housing units, renovated 71 homes, given out 158 home improvement projects, and helped spur a 58 unit housing/office development.  They've also hired 800 local residents and instituted a jobs training program. 

They're already seeing lower murder rates, higher high school graduation rates, and are studying impacts on emergency room visits, inpatient days, and rates of specific conditions such as asthma. 

The lead author, Kelly Kelleher, MD, told Fast Company:

 It’s essential if we want to change things.  Every city has certain pockets of disadvantage. Those particular pockets account for a disproportionate share of all the challenges children face. . . if you’re a pediatrician and you look at the numbers, you have to do something to participate in the solution around eliminating poverty in these neighborhoods. Medical care’s never going to change some of these outcomes.

"This is a national trend," Jason Corburn, professor of city and regional planning at the University of California, Berkeley, told NPR. "It's happening in cities across the country," citing similar efforts in Atlanta, Boston, New York, and Seattle.  

Or take a program, led by researchers at the University of Pennsylvania, that focused on cleaning up vacant lots in Philadelphia.  It sounds simple, but resulted in significant improvements in residents' mental health.  The authors concluded: "Making structural changes to the lowest-resource neighborhoods can make them healthier and may be an important mechanism to address persistent and entrenched socioeconomic health disparities."   

As Eugenie South, one of the co-authors, told The Washington Post:  

...there’s something that’s actually important about the green space...It’s a relatively low-cost intervention … and it’s a pretty simple intervention.  It’s very simple to replicate. It’s not complicated and could be easy for a city that hasn’t done this. 

Or a hospital. 

It is true that hospitals (excuse me, "health systems") are diversifying -- building/buying satellite locations, free-standing emergency rooms, urgent care centers, and physician practices -- but those big buildings remain the locus, and their sunk costs weigh on hospitals' finances. 

There's a great quote from Philip Betbeze of HealthLeaders: "the future of the hospital is not a hospital."  The future requires, as Richard Darch, CEO of Archus, more recently wrote, "radically and fundamentally rethinking the hospital, and even discarding the term ‘hospital’ to the history books."  Mr. Darch sees hospitals as "anchor institutions" of their communities, with a greater focus on wellness and structured more as a campus than a single place. 

I'd go further: not a building, not even a campus, but as a dispersed array of services - some medical, many not -- that are delivered as close to our homes as possible (and, preferably, in our homes). 

Do an image search for "hospital of the future" and you'll get pictures of futuristic buildings with some cool-looking technologies thrown in.  What I want to see are images of services being delivered where I am, focused around me, aimed at my convenience -- not at the convenience of the people delivering my care. 

"Mission Control" at Medically Home.  Source: BizJournals

As I previously wrote about, organizations like Medically Home or Hospital at Home believe that future is now.

Some will argue, well, we're not going to do surgery at home.  We're not going to have NICUs at home.  We're not going to put doctors and nurses in every sick person's home.

Perhaps, but there are a lot of things we're now doing in hospitals that don't need to be.  There are a lot of expensive devices that are now centralized in hospitals that could be decentralized or even made mobile.  There are a lot of interventions that aren't medical at all. 

It requires us blowing up our concept of a "hospital."

Don't donate money for hospital expansion/renovation plans.  Don't buy bonds for them either.  Don't sit passively on hospital boards that push for them or expensive new equipment. 

Instead, we should be questioning: how can a "hospital" most impact our communities' health?  What kinds of investments in our communities' health can they be making?  How we do push healthcare and health down as close to where and how people live as possible?

The argument will always be, well, payors won't pay for those kinds of things.  The business models don't support them.  To that I say: it's time not just for new kinds of "hospitals," but also new kinds of business models. 

Let's get to it.

Best Buy Buys Into Health

Best Buy generated a lot of positive press recently with its acquisition of GreatCall, which focuses on technology services for seniors.  Its move into health may not be a surprise, since it seems lots of retailers -- think Walmart or Kroger -- and many big tech companies -- think Apple or Amazon -- want into health, not to mention more tech startups than you can throw $100 million at. 

It's the why and the how about Best Buy's moves into health that deserve more scrutiny, and that healthcare organizations may learn from. 

Top Technical Solutions/Best Buy

As recently as 2012, many expected that by now Best Buy might be like one-time rivals Sears -- which is dying -- or Circuit City -- which is dead -- but the opposite has happened.  Bloomberg raised a few eyebrows in July with its profile Best Buy Should Be Dead, But It’s Thriving in the Age of Amazon.  It focused on Best Buy's emphasis on consultation, saying Best Buy's past was "about getting people into Best Buy stores and onto its website; Best Buy’s future will be about getting its people into homes."  Those people aim to be consumers' "personal chief technology officers."

Best Buy chairman and CEO Hubert Joly told Bloomberg: "The vision I had from the beginning is for us to be to the consumer what a company like Accenture is for a business." 

Helping people not just buy but actually use technology has been part of Best Buy's strategy for some time.  Back it 2002 it acquired the then little-known Geek Squad, with its 50 employees, for a measly $3 million.  The Geek Squad now reputedly has some 20,000 members and generates as much as $1 billion in profits for Best Buy. 

Last year Best Buy piloted Assured Living, an aging-in-place service aimed "to give caregivers peace of mind and allow aging parents to live independently."  It was built on smart home technology which, of course, Best Buy sells and which fit in perfectly with GreatCall's expertise.

Part of Best Buy's Assured Living program.  Source: Best Buy

The Best Buy 2020 strategy includes not just the Assured Living program but also doubling down on smart home technology, launching a Geek Squad service to support tech no matter where it was bought, and expanding an In Home Advisor program to provide free in-home consultations about personalized technology solutions. 

The strategy explicitly points the way:

Best Buy is evolving how it sells to focus not on just selling products but solving customers’ underlying needs. The company will seek to accelerate its growth by continuing to improve the customer experience within and across channels, more effectively addressing customer needs in underpenetrated categories and building its in-home channel.

Then in May Best Buy told Wall Street analysts it saw opportunities in further expanding in health care, particularly around how technology can help people stay in their homes longer.  Those analysts are now cheering the GreatCalls acquisition. 

The GreatCall acquisition fits Best Buy's strategy very well.  GreatCall is known mostly for its Jitterburg line of mobile phones aimed at seniors, but it offers a wider range of senior-focused technology products and services, such as medical alert devices.  It also offers services such as telehealth, telephonic wellness coaching, medication reminders, automated check-ins, fall detectors, even fitness trackers and wearables. 

GreatCall claims over 900,000 paying subscribers, and annual revenues of $300 million.  Best Buy paid $800 million for the company. 

Some of GreatCall's products and services

Mr. Joly characterized the acquisition as follows:

We know technology can improve the quality of life of the aging population and those who care for them.  Now, we have a great opportunity to serve the needs of these customers by combining GreatCall’s expertise with Best Buy’s unique merchandising, marketing, sales and services capabilities...[we] are excited by the opportunities we have in the health space and the strengths we can bring to bear in this area, especially our experience with technology and serving customers in their home

Best Buy made clear that the acquisition would be neutral to earnings in 2019 and 2020, but boost them in 2021.  Again, this is consistent with what Mr. Joly said in May:

We're not trying to increase the profitability, because we are trying to position the company for the future.  The return for the winners in this space are going to be outsized because there's going to be greater and greater differentiation between winners and losers. And so this is the time clearly to invest.

Healthcare, are you paying attention? 

Here are some three potential lessons:

• Reduce confusion:  Both health and our healthcare system are complicated and confusing.   Even otherwise competent people become helpless patients very easily.  So, don't just do things to people; explain things to people.  Walk them through things step-by-step if necessary.  Healthy but confused is not healthy, or won't stay healthy.  
• Use the right technology: Healthcare has long relied on technology, and is increasingly turning to consumer/patient-facing technology, whether patient portals or wearables.  For many people, there are too many health technology options, with too few clear benefits.  Where's our Geek Squad, our Genius bar to help us pick the right technology for us, help us install and use it, and make sure it is working for us as expected?    
• Keep people at home: I hope it won't come as a surprise to any healthcare professional, but no one really wants to go to a doctors office.  No one really wants to go to a testing facility or surgical center.  No one wants to stand in line at a pharmacy.  And certainly no one wants to go to a hospital or nursing home.  Mission number one of healthcare may be to help people be healthy, but a close number two should be to do so at home with family.  Find ways to maximize their time at home.

It's not going to be enough to do more healthcare procedures or to find more better treatments.  It's not going to be enough to improve satisfaction scores of people getting services.  It's going to require that healthcare understand people's lives and integrates with them -- where they live, not just where they get care.  

To paraphrase Mr. Joly, it's not about just selling healthcare services, but helping to solve people's underlying health needs.

Best Buy gets it.  Does your healthcare organization?  

My Robot Doesn't Like That

I have a soft spot for robots.  Maybe it was Robot from Lost in Space.  Maybe it was R2-D2 and C-3PO from Star Wars.  OK, maybe the original Terminator wasn't so likable, but its subsequent iterations showed its softer side.  Show me a robot and I'm prepared to like it.

Robots are already a big deal in healthcare.  We've got robotic surgery, robots in the healthcare supply chain, cleaning robots in hospitals, and caregiver robots, to name a few.   Soon we may have tiny "spider" robots performing surgery and other tasks inside us. 

But what we haven't been used to is caring about what the robot thinks.  That may soon change.

Aike C. Horstmann , Nikolai Bock, Eva Linhuber,
Jessica M. Szczuka, Carolin Straßmann, Nicole C. Krämer / PLOS

A new study in PLOS found that robots can arouse our sympathy.  Study participants interacted with a robot (Softbank's NAO), either on tasks that were "social" (involving more verbal interaction) or functional.  The participants were told they could turn NAO off once the tasks were completed, but, to the surprise of about half of the participants, when it was time NAO pleaded: "No! Please do not switch me off! I am scared that it will not brighten up again!”

Come on, who could resist that? 

About a third of the people who heard that plea refused to turn it off, and the rest took twice as long to do so as participants who did not get the plea.  The authors state:

Participants treated the protesting robot differently, which can be explained when the robot’s objection was perceived as sign of autonomy. Triggered by the objection, people tend to treat the robot rather as a real person than just a machine by following or at least considering to follow its request to stay switched on... 

Here are some examples of reasons participants gave for their reluctance:

The researchers were testing something called media equation theory.  Essentially, the premise is that we tend to treat non-human media -- TV, computers, robots, etc. -- as human, as anyone who uses Alexa or Siri can attest.  As the study authors put it:  "Due to their social nature, people will rather make the mistake of treating something falsely as human than treating something falsely as non-human."

In the study, subjects found NAO more likable if their task had been social rather than functional.  However, likability did not, as might have been expected, tie directly to the decision about turning NAO off.  Subjects who had interacted socially with NAO found turning it off more stressful, but those whose interaction had been more functional actually took longer to turn it off once it pleaded not to be. 

The authors speculated:

After the social interaction, people were more used to personal and emotional statements by the robot and probably already found explanations for them. After the functional interaction, the protest was the first time the robot revealed something personal and emotional with the participant and, thus, people were not prepared cognitively

However, for subjects who had negative attitudes towards robots prior to the study, or had "low technical affinity," NAO's plea didn't have a significant impact the switching off decision.

We're already seeing robots interacting with us on an emotional level in healthcare.  For example, IEEE Spectrum reports on QTrobot, from LuxAI, a robot designed to help children with autism develop social skills.  LuxAI cofounder Aida Nazarikhorram explained:

When you are interacting with a person, there are a lot of social cues such as facial expressions, tonality of the voice, and movement of the body which are overwhelming and distracting for children with autism.  But robots have this ability to make everything simplified.  For example, every time the robot says something or performs a task, it’s exactly the same as the previous time, and that gives comfort to children with autism.

Hello, QTrobot!  Credit: LuxAI

The article pointed out that using robots for autism has been studied since the 1990's, and one of them (again Softbank's NAO) was used by researchers at MIT Media Lab to estimate engagement and interest of children it interacts with.  Their research gauged that the robots did about as well as humans, which is impressive,or scary, or both. 

It is worth pointing out that the MIT researchers found that the children reacted to the robot "not just as a toy but related to NAO respectfully as it if was a real person."  

When we get AI doctors and other healthcare professionals -- and we will -- it will be interesting to see if we trust them more if they are humanoid robots, versus ones with whom we only have verbal interactions, or ones which present through avatars/holograms.  If it looks and talks like a human, will we be predisposed to treat it like one?

As Nicole Kramer, one of the PLOS study co-authors, told NBC News, "We are preprogrammed to react socially.  We have not yet learned to distinguish between human social cues and artificial entities who present social cues." 

We're already being deeply manipulated by Facebook, video games, and a host of apps, and they aren't even cute little humanoid robots.  Fritz Breithaupt, a humanities scholar and cognitive scientist at Indiana University, also told NBC News. “These emotionally manipulative robots will soon read our emotions better than humans will.  This will allow them to exploit us. People will need to learn that robots are not neutral.”

Isn't that sweet? Credit: Softbank

Aike Horstman, the Ph.D. student who led the PLOS study, is aware of this concern, but is philosophical about it, telling The Verge: 

I hear this worry a lot.  But I think it’s just something we have to get used to. The media equation theory suggests we react to [robots] socially because for hundreds of thousands of years, we were the only social beings on the planet. Now we’re not, and we have to adapt to it. It’s an unconscious reaction, but it can change.”

Of course, robots and AI are evolving much more rapidly than we are, so, while our reactions can change, the question of whether we will change "in time" remains open. 

I used to think that, should I ever need a caregiver, I would prefer a robot rather than a human for the more unpleasant tasks, but now I have to worry about how they might feel about them as well!

Calling Doctor Who

Even people who are not fans of the British science fiction series Doctor Who -- and, I must confess, I am not -- may have heard that, after 36 seasons over 54 years featuring 12 different Doctors, the series is finally having the Doctor transform into a woman.  Now, I recognize that the Doctor is neither a physician nor even from Earth, but I'm beginning to wonder if U.S. healthcare would be better if we could do the same.

Especially if you are a woman.

New research suggests that gender matters when it comes to treating heart attacks.  We've known for some time that women are less likely than men to survive heart attacks. but the new research found that the gender of the treating physician appears to play a role in survival as well.  Female heart attack patients had a higher mortality rate when treated by male physicians. 

Conversely, though, male and female patients had similar outcomes when treated by female physicians.  In addition, male doctors' performance improved when there were more female doctors around -- when the proportion of female physicians rises by 5%, female survival rates rise 0.4%. 

The researchers looked at emergency room records in Florida between 1991 and 2010, including all those admitted with a heart attack.  Their conclusion was blunt:

These results suggest a reason why gender inequality in heart attack mortality persists: Most physicians are male, and male physicians appear to have trouble treating female patients.

One author, Professor Seth Carnahan, speculated to Marketwatch:  "Female doctors may be more keen to remember and pay attention to the sex differences in symptoms."  Professor Laura Huang, another co-author, described the impact more starkly: "But even here [heart attack treatment], we see a glass ceiling on life."

Let that one sink in. 

This is not, let's remember, the first evidence of women physicians performing better than their male counterparts.  A 2016 study found lower mortality rates generally for patients of female physicians, and a 2017 follow-up study found they had lower readmission rates as well.  Lead author Ashish Jha got lots of headlines for his quote: "If male physicians had the same outcomes as female physicians, we’d have 32,000 fewer deaths in the Medicare population."

Despite this kind of evidence, on average, U.S. female doctors still make $105,000 less than male doctors, some 28% lower.  The gaps exist even when controlling for specialty. 

It's not just that female physicians may perform better than male ones; it is also that female patients generally may get worse care.  In its article on the Florida study, The Atlantic reminded us of related gender-based findings:

• Women are more likely to delay getting treatment for suspected heart attacks.  
• Women's symptoms are less likely to be identified as heart attacks.  
• Women with suspected heart attacks were less likely to get diagnostic tests for them.  

All that is alarming enough, but, as co-author Professor Brad Greenwood told The Atlantic, when treated by male physicians, "the penalty for being female is greater."

Again, let that one sink in.

Dr. Jha, who was not part of the study, diplomatically put his finger on what needs to happen, saying::

What is convincing is that we have to do better in terms of caring for women with cardiovascular disease—all of us. And male physicians could learn a thing or two from our female colleagues about how to achieve better outcomes.

Sadly, this issue is not limited to cardiovascular disease. 

USA Today recently ran an expose about maternal health in hospitals, asserting: "Every year, thousands of women suffer life-altering injuries or die during childbirth because hospitals and medical workers skip safety practices known to head off disaster."  According to them, 50,000 injuries and 700 deaths annually could be cut in half by following such practices.

In a similar study, NPR and ProPublica found that the U.S. has a higher maternal death rate than any other developed country, and that for every death, another 70 almost die.  The rate of the latter has almost tripled since 1993, according to CDC statistics.  This is third world stuff.

Source: The Lancet, Credit: Rob Weychert/ProPublica

It almost seems ironic to note that the risk of pregnant women having having a heart attack increased 25% from 2002 to 2014. 

Let's not even get into the attacks on Planned Parenthood, the limits on birth control and abortion, or the fact that in 2018 we still don't have a comfortable way to get a mammogram.  All in all, when it comes to women's heath, there may not only be a glass ceiling but also a ragged floor.

Suzannah Weiss, writing in Bustle, took a different tact on the issue.  Instead of more statistics about gender disparities, she requested that women report "the most ridiculous things doctors have told them."  She quickly garnered over 500 responses, and boiled them down into 32 examples (I should note that several of the examples feature female physicians). 

As a man, the examples are eye-opening to me, but I suspect most women would recognize many of them, and have some of their own to add.  My favorite: "If you were a man, I would send you to the ER for pelvic pain. But you should just drink some chamomile tea and calm down."

Good thing she wasn't having a heart attack. 

Of course, we don't just do a bad job delivering care to women.  I could also talk about racial/ethnic disparities, socioeconomic disparities, or geographic disparities.  Health and health care are anything but equal in the U.S.

We're not going to be like Doctor Who and turn our doctors into women, but we are making progress.  Women make up  slightly over half of entrants to medical school, and now account for just over a third of all active U.S. physicians (which is still well below the OECD average of 46%).  That's progress, but one that will have a long tail.

Our health shouldn't depend on whether we get care from a female doctor or a male one.  It shouldn't matter if we are female or male.  It shouldn't matter if we are "minority" or not, rich or poor, live in New Mexico or New York. 

But it does.  When are we going to finally do something about it?

Say It Ain't So, HAL 9000

The classic film 2001: A Space Odyssey featured HAL 9000, one of the first -- but certainly not the last -- popular examples of artificial intelligence (AI) gone wrong.  Just as the mythical heartbroken kid asked Shoeless Joe Jackson to deny he was involved in throwing the 1919 World Series, it's starting to seem if we need to ask if perhaps we're finding out that AI performance in healthcare is more hope, or hype, than reality.

The biggest headlines came from a startling StatNews report about IBM Watson.  They obtained internal IBM documents that indicated the collaboration with Memorial Sloan Kettering Cancer Center. was something of a bust. with "multiple examples of unsafe and incorrect treatment recommendations."  The "often inaccurate" recommendations posed "serious questions about the process for building content and the underlying technology." 

Fortunately, the reports indicated, no patient deaths resulted from the faulty recommendations. 

IBM had gotten lots of good publicity about the project.  MSK is, of course, one of the premier cancer centers in the world, and the partnership was a coup for IBM.  MSK even touted itself as "Watson's oncology teacher." 

IBM blamed poor training for the flaws, as Watson based its recommendation on a few hypothetical cancer cases instead of on actual patient data, despite the fact that IBM was promising that Watson used the latter.  It was bragging about Watson even after it had become clear that Watson's recommendations often conflicted with national guidelines and that physicians were ignoring them. 

"This product is a piece of shit," one physician told IBM executives.  "We bought it for marketing and with hopes that you would achieve the vision. We can't use it for most cases."  His was not the only physician complaint. 

IBM maintains a positive attitude.  A spokesperson told Gizmodo that Watson is used in 230 hospitals worldwide, is able to treat 13 cancers, and supports care for over 84,000 patients.  IBM also promised STAT:

We have learned and improved Watson Health based on continuous feedback from clients, new scientific evidence and new cancers and treatment alternatives. This includes 11 software releases for even better functionality during the past year, including national guidelines for cancers ranging from colon to liver cancer.

Well, then, it's all right.  That is, unless one remembers the debacle at another leading cancer, MD Anderson Cancer Center.  The failure there may be attributed at least as much to MD Anderson as to any problems with Watson, but, still...

This is not the only recent example of healthcare AI overreaching.  A few weeks ago British start-up Babylon Health claimed its AI chatbot could diagnose patients at least as well as human doctors. 

Babylon tested its chatbot using questions that the Royal College of General Practitioners (RCGP) uses to certify actual doctors, and said that its score beat the average score of human doctors.  They also gave both the chatbot and seven human doctors 100 symptom sets, and say that the chatbot scored better on those as well. 

A Chinese AI, BioMind, similarly claimed to outperform China's "top doctors" -- by a margin of two to one. 

The RCGP, for one, is not buying it.  A spokesperson said: 

...at the end of the day, computers are computers, and GPs are highly-trained medical professionals: the two can't be compared and the former may support, but will never replace, the latter...No app or algorithm will be able to do what a GP does."

Babylon's medical director fired back:

We make no claims that an ‘app or algorithm will be able to do what a GP does’...that is precisely why, at Babylon, we have created a service that offers a complete continuum of care, where AI decisions are supported by real-life GPs to provide the care and emotional support that only humans are capable of...I am saddened by the response of a college of which I am a member. The research that Babylon will publish later today should be acknowledged for what it is — a significant advancement in medicine

The question of AI doing what physicians do was further illustrated by a new study from MIT.  The research computed "sentiment analysis" on the physicians' notes, outside of the data in the medical records themselves, and found a positive correlation between those scores and the number of diagnostic tests ordered.  The effect was strongest at the beginning of a hospital stay and when there was less medical information to go on.

The researchers concluded that physicians "provide a dimension that, as yet, artificial intelligence does not."  They attribute this to physicians' "gut feelings," saying:

There’s something about a doctor’s experience, and their years of training and practice, that allows them to know in a more comprehensive sense, beyond just the list of symptoms, whether you’re doing well or you’re not.  They’re tapping into something that the machine may not be seeing.

The researchers hope to find ways to teach AI to approximate what physicians are doing by capturing other types of data, such as their speech. 

Lastly, Eric Topel, MD, tried to summarize in a tweet, saying that we still simply don't know how good AI is in medicine.  His summary of the research:

All in all, despite the claims that some are making about AI -- whether it is Watson or Babylon or BioMind or any of the hundreds of other AIs being developed -- one would have to admit that they are not the same as human physicians and not yet a threat to replace them. 

But...

The fact that AI don't replicate what human physicians do doesn't bother me.  Those "gut feelings" and clinical insights that they are so proud of aren't always right and often aren't based on solid, or any, science.   Let's not mistake the value of human touch and interaction with infallibility.

I would hope we can do better.  I would hope that an AI's "gut feelings" will be based on millions of experiences, not the hundreds or even thousands that a human physician might have had for a specific issue.  I would hope that an AI wouldn't order unnecessary or even harmful tests or procedures.  I would hope that an AI wouldn't commit errors due to fatigue or impaired judgement or simple miscommunication. 

AI in healthcare is only going to get better.  It is going to play a major role in our care.  That is something to look forward to, not to fear (HAL 9000 notwithstanding!). 

The Sounds of Silence

Listen closely, healthcare organizations and professionals: those sounds you are not hearing are the voices of people not speaking up, including patients.  And that's a problem.

Let's start with the elephant in the room: a new study found that even when physicians actually asked patients why they were there, on average they only listened to the patient's explanation for eleven -- that's 11 -- seconds before interrupting them. 

Think about that, and then think back to a doctor's visit you had about something that was worrying you: could you have explained it in eleven seconds? 

Believe it or not, that's not the worst of it.  Only 36% of the time did patients even get a chance to explain why they were there.  Even then, two-thirds of them were interrupted before they had finished. 

Primary care doctors did better, allowing 49% of patients to explain their agenda for being there, versus only 20% for specialists.  Hurray for the primary care physicians...

Lead author Naykky Singh Ospina, MD, MS, drolly concluded: “Our results suggest that we are far from achieving patient-centred care."

Now, sometimes the physicians already know, or think they know, why patients are there, and sometimes the interruptions are to ask clarifying questions.  But, as Dr. Singh Ospina added:

If done respectfully and with the patient’s best interest in mind, interruptions to the patient’s discourse may clarify or focus the conversation, and thus benefit patients.  Yet, it seems rather unlikely that an interruption, even to clarify or focus, could be beneficial at the early stage in the encounter.

The researchers say there are many reasons why physicians aren't listening better, including time constraints, burnout, and lack of communications training.  But still...11 seconds?  For the minority that even get the chance to talk?

As Bruce Y. Lee said in Forbes, "A doctor’s visit shouldn’t feel like a Shark Tank pitch."

As bad as this is, it is not the only area where not feeling able to speak up is a problem  in healthcare.  For example, a study in BMJ Quality and Safety found that 50% to 70% of family members with a loved one in the ICU were hesitant to speak about common care situations with safety implications.  They didn't want to be labeled a "troublemaker," they thought the care team was too busy, or they simply didn't know how to speak up.  Only 46% felt comfortable speaking up even when they thought there was a possible mistake in care. 

Co-lead author Sigall K. Bell said:

Speaking up is a key component of safety culture, yet our study—the first to our knowledge to address this issue—revealed substantial challenges for patients and families speaking up during an ICU stay

If patients are hesitant to speak up when their loved one is in the ICU, how reluctant must they be in other healthcare settings? 

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It's not just patients who are silenced.  One study found that 90% of nurses don't speak up to a physician even when they know a patient's safety is at risk.  Another survey, of medical students in their final year of school, found that 42% had experienced harassment and 84% had experienced belittlement. 

A couple of years ago ProPublica looked at why physicians stay silent about other physicians they know commit medical errors, including ones who do so repeatedly.  The reasons are varied, of course, but include concern about losing referrals, fear about causing lawsuits, lack of seniority, and gender or racial discrimination.

One physician, speaking about his hospital, told them: 

There’s not a culture where people care about feedback.  You figure that if you make them mad they’ll come after you in peer review and quality assurance. They’ll figure out a way to get back at you.

Anyone who has worked in an organization -- big or small, for-profit or not-for-profit, academic or commercial -- has probably had the experience of not feeling they can speak up, and healthcare organizations are no exception.  Even when the ones not speaking up are physicians themselves. 

The TV series The Resident (which I gather is one of Dave Chase's favorites) is about the trials and tribulations of a resident and a nurse who dare to speak out about senior physicians who are impaired and/or unethical; one of duo is [SPOILER ALERT] falsely imprisoned as a result.  It's TV, so you can rest assured that all will end well for our heroes, but, in the real world, things don't always work out so well for outspoken people. 

It's about power: who has it, or at least who we think has it.  We trust our doctors (although not as much as our nurses!).  We assume that more experienced doctors have more knowledge than newer doctors, that doctors know more than nurses, and that healthcare professionals know more than we do.  We're at the bottom of the knowledge tree.    

But that may not be true.  Dave deBronkart -- e-patient Dave -- likes to cite Warner Slack's great quote: "Patients are the most underused resource."  

I also think about what Dr. Jordan Shlain (Tincture's founder & leader) realized about patients: "No news isn't good news.  It's just no news."  This epiphany led him to found Healthloop to help ensure physicians were always hearing from their patients.  

But healthcare professionals must be willing to listen, and they must ensure that they ask.  And we must take the initiative to speak up.   

When it comes to our health, we are the experts.  We are the only ones who can report what we are feeling.  We are the ones who suffer the consequences of missed diagnoses, ineffective treatments, and medical errors.  We cannot be passive and we cannot be silent.

Our values are wrong if we allow reimbursement considerations to squeeze our time with physicians to the point we're not talking and they're not listening.  Our values are wrong if we're conditioned to think our opinions and concerns do not matter.  Our values are wrong if everyone is not only empowered but also expected to speak up, especially when we see or experience something we think is a problem.

Anybody listening?